Ahmed NM Ghanem1*
1NHS The UK and Mansoura University, Faculty of Medicine Egypt; Consultant Urologist Surgeon- Retired Independent Investigator & Scientist, Free Lance Author, Dreamer & White Revolutionary in Science, 5 Wroughton Terrance, London, NW4 4LE.The3 UK; No 1 President Mubarak Street, El-Mansoura, Egypt
*Correspondence author: Ahmed NM Ghanem, MD (Urology), FRCSE Ed, NHS The UK and Mansoura University, Faculty of Medicine Egypt; Consultant Urologist Surgeon- Retired Independent Investigator & Scientist, Free Lance Author, Dreamer & White Revolutionary in Science, 5 Wroughton Terrance, London, NW4 4LE. The3 UK; No 1 President Mubarak Street, El-Mansoura, Egypt; Email: [email protected]
Published On: 28-06-2023
Copyright© 2023 by Ghanem ANM. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Editorial
I read with great interest this recently published article by Professors Dull RO and Hahn RG [1]. The authors are commended on this review based on evidence from published studies that represent the current understanding of the condition and its scientific basis. The authors have faithfully and factually summarized the evidence based on published reports, including some of the commonly received errors and misconceptions on the scientific foundation that identifying and correcting may help to answer the vitally important question in the title of the report.
The authors acknowledge that Starling’s law represents the scientific foundation of the volume-pressure relationship of the vascular, capillary and interstitial fluid compartments. It thus underlies the rules that govern fluid therapy in shock management. This is the subject on which both authors are among the top world authority. My research has demonstrated clearly and completely the substantial evidence that Starling’s law is wrong and the correct replacement is the hydrodynamics of the porous orifice (G) tube that has been gathered in a book [1-3]. This will revolutionize our understanding of the condition and related issues, particularly on the path-etiology and management of Acute Respiratory Distress Syndrome (ARDS). The hydrodynamics of the G tube in a surrounding chamber mimics the capillary-ISF transfer.
Hypovolaemia and peripheral oedema refer to the condition that affects acutely ill patients presenting with any shock then suffer clinically with ARDS induced by excessive fluid therapy in whom there is massive volumetric overload with hypotension shock (Hypovolaemia) and massive fluid creep on the interstitial fluid space causing generalized oedema. It complicates fluid therapy for shock resuscitation of burns, sepsis, haemorrhage, trauma and acute pancreatitis [4,5]. It initially presents and seamlessly occurs as volume kinetic or Volumetric Overload Shock (VOS), among new scientific discoveries in physics, physiology and medicine [6,7]. It has high morbidity and mortality and affects thousands of patients every year all over the world. Although there is hypotension shock here it is probably incorrect to assume hypovolaemia exists. In other words, and contrary to what generally believed, hypotension is not synonymous with hypovolaemia. It is a simple physics: if the cardiovascular system is overfilled to above its maximum capacity, the surplus will simply spill into the ISF space!
Starling’s law has proved wrong on both of its hydrostatic and oncotic pressure forces [2]. However, it continues to dictate the current faulty rules on fluid therapy in the management of shock. It thus misleads physicians into giving too much fluid during shock resuscitation [8]. More than 21 reasons were reported to show that Starling’s law is wrong [9]. The correct replacement is the hydrodynamic of the porous orifice (G) tube that was built on the capillary ultrastructure anatomy of the precapillary sphincter and a porous wall that allow the passage of plasma proteins thus nullifying the oncotic pressure in-vivo [10,11]. It follows that the extended starling principle is wrong and a misnomer and all the equations are also wrong. Commonly received but erroneous concepts and laws represent fraud in modern science.
The clinical significance is that Starling’s law dictates the faulty rules on fluid therapy causing many errors and misconceptions that mislead physicians into giving too much fluid infusions of albumin and crystalloids for the resuscitation of shock which both cause oedema of ISF space and vital organs as well as “hypervolemia” with hypotension [5,8,12]. This shock is mistaken for septic shock or any known shock and is wrongly treated with further huge volume expansion, occurring with both liberal and conservative approaches of fluid therapy. This has been newly recognized as volume kinetic or Volumetric Overload Shocks (VOS).
Volumetric overload inducing VOS is of 2 types: VOS 1 is induced by sodium-free fluid that causes the Transurethral Resection of the Prostate (TUR) syndrome [6,12]. VOS 2 is induced by sodium-based fluids of crystalloids and plasma proteins and causes ARDS and Acute Kidney Injury (AKI) as part of the Multiple Organ Dysfunction Syndrome (MODS) with high morbidity and mortality [11]. Volumetric overload shock induced by persistence to elevate CVP to a high level of 20-22 mmHg during shock resuscitation is also based on the faulty Starling’s law. ARDS was originally reported by Ashbaugh, et al., in 1967 in which the dead patients had 12-14 Litres of fluid creep retained in their bodies [13]. In recent huge prospective multicenter clinical trial studies, fluid retention is 7-10 L in surviving ARDS patients [14].
I trust the respected authors and invite the world authorities, to kindly fulfil their authority and responsibility by writing an update on the subject that summarizes the results of my recently reported research for the awareness of the doctors’ readers and the benefit of their patients.
Conflict of Interest
The author has no conflict of interest to declare.
Availability of Data and Materials
The datasets used can be accessed from the given references of published articles.
References
- Dull RO, Hahn RG. Hypovolemia with peripheral edema: What is wrong? Crit Care. 2023;27:206.
- Ghanem AN. Final affirmative proof starling’s law wrong and g tube hydrodynamic is the correct replacement: new results and critical analytical criticisms of impactful landmark articles. Biomed J Sci & Tech Res. 2021;33(5).
- Ghanem AN. New scientific basis of fluid therapy in shock management: the complete evidence based on new scientific discoveries in physics, physiology, and medicine. Book Publisher Austin Macauley Publishers Ltd ®, London. 2023;35:516.
- Ghanem ANM, Ghanem K. “Fluid Creep” in critically Ill ARDS surgical patients: time to stop the flood?. EC Emergency Medicine and Critical Care. 2022;6(9):9-13.
- Ghanem ANM. Fluid creep in ARDS after shock resuscitation of trauma, burns, sepsis, and acute pancreatitis patients: how much, where, and how to find it? J Cardiol. 2023;7(1):000176.
- Ghanem AN. Volume kinetic shocks in surgical practice. J Emergency Medicine, Trauma and Surgical Care. 2020;2;10.
- Ghanem AN. Update on ghanem’s new scientific discoveries in physics, physiology and medicine. Clinics of Oncology. 2020;3(3):1-5.
- Ghanem AN. What is misleading physicians into giving too much fluid during resuscitation of shock and surgery that induces ARDS and/or AKI? Asploro J Biomedical and Clinical Case Reports. 2020;2020(1):90.
- Ghanem AN. Twenty-one reasons affirming Starling’s law on the capillary-interstitial fluid transfer wrong and the correct replacement is the hydrodynamic of the porous orifice (G) tube. Case Rep Open A Open J. 2020;1(1):8-11.
- Rhodin JA. The ultrastructure of mammalian arterioles and precapillary sphincters. J Ultrastructure Res. 1967;18(1-2):181-223.
- Karnovesky MJ. The ultra-structural basis of capillary permeability studied with peroxidase as a tracer. J Cell Biol. 1967;35(1):213-36.
- Ghanem AN. Volumetric overload shocks cause the acute respiratory distress syndrome: building the bridge between physics, physiology, biochemistry, and medicine. Biomed J Sci and Tech Res. 2020;29(1).
- Ashbaugh DG.Acute respiratory distress in adults. The Lancet Saturday. 1967.
- Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R. Early, goal-directed therapy for septic shock – a patient-level meta-analysis. The New England J Med. 2017;376(23):2223-34.
Article Type
Editorial
Publication History
Received On: 06-06-2023
Accepted On: 20-06-2023
Published On: 28-06-2023
Copyright© 2023 by Ghanem ANM. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Ghanem ANM. Hypovolemia With Peripheral Edema: What Is Wrong? J Surg Res Prac. 2023;4(2):1-3.
